About the Author(s)

Jennifer N. Githaiga Email symbol
Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

Fiona M. Walter symbol
Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, London, United Kingdom

Suzanne E. Scott symbol
Centre for Oral, Clinical and Translational Sciences, King’s College London, London, United Kingdom

Amos D. Mwaka symbol
Department of Medicine, Makerere University, Kampala, Uganda

Jennifer Moodley symbol
Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

SAMRC Gynaecology Cancer Research Centre, University of Cape Town, Cape Town, South Africa


Githaiga JN, Walter FM, Scott SE, Mwaka AD, Moodley J. Symptom awareness measures for breast and cervical cancer in sub-Saharan Africa: A scoping review. S. Afr. j. oncol. 2019;3(0), a78. https://doi.org/10.4102/sajo.v3i0.78

Review Article

Symptom awareness measures for breast and cervical cancer in sub-Saharan Africa: A scoping review

Jennifer N. Githaiga, Fiona M. Walter, Suzanne E. Scott, Amos D. Mwaka, Jennifer Moodley

Received: 15 Mar. 2019; Accepted: 24 Apr. 2019; Published: 26 June 2019

Copyright: © 2019. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Background: In sub-Saharan Africa (SSA), breast cancer is the most commonly diagnosed cancer among women, while cervical cancer remains the leading cause of cancer death. Women often fail to recognise or misinterpret possible symptoms, so breast and cervical cancer symptom awareness information can promote timely help-seeking behaviour, diagnosis and start of treatment.

Aim: To identify tools that have been utilised to measure breast and cervical cancer symptom awareness in SSA and to establish if such tools have been validated in SSA populations.

Methods: A scoping review of articles published between January 1997 and February 2017, written in English and describing primary research in breast and/or cervical cancer symptom awareness-related topics in SSA contexts, was undertaken across five databases. The approach was supported by Colquhoun et al.’s methodological framework for scoping reviews.

Results: A total of 41 studies were included from 11 SSA countries. Almost half (20/41) used breast and/or cervical cancer symptom awareness tools but did not report on tool validation processes. The rest (21/41) made reference to some tool validation, yet only two reported a detailed account of their tool validation processes. One explored lay perceptions of breast cancer, while the other sought to establish the validity and reliability of a UK tool in a Kenyan context.

Conclusion: The findings point to the dearth of comprehensively validated and culturally relevant tools to measure breast and cervical cancer symptom awareness in the SSA context. They have informed the development and validation of an African Women Awareness of CANcer (AWACAN) tool, which can support the development and evaluation of interventions relevant to the SSA context.

Keywords: scoping review; breast and cervical cancer; symptom awareness measures; sub-Saharan Africa.


Breast and cervical cancers are the leading cause of cancer morbidity and mortality in women. In sub-Saharan Africa (SSA), breast cancer is the most commonly diagnosed cancer among women, while cervical cancer remains the leading cause of cancer death.1 Yet, if diagnosed early, both cancers are treatable with curative intent. Worldwide, most cancers (85% – 90%) are diagnosed following symptomatic presentation.2 Consequently, understanding processes related to cancer symptom epidemiology, symptom awareness and responses to symptoms are important in developing interventions to promote timely cancer diagnosis. For both breast and cervical cancers, women often fail to recognise or misinterpret these symptoms or wait until symptoms (and disease) progress before they seek medical attention.3,4,5,6 For example, patients in Nepal have been shown to be more likely to recognise vaginal bleeding and seek care for symptoms, in contrast to recognising foul smelling vaginal discharge.5 For breast cancer, women are more likely to recognise and seek care for breast lumps in contrast to non-lump symptoms.6 There is evidence that interventions to increase awareness lead to better outcomes.7 For instance, a Malaysian study reported earlier help-seeking for breast and cervical cancers following an intervention targeted at raising public awareness of symptoms of these cancers.8 This suggests that breast and cervical cancer symptom awareness and interpretation can promote timely help-seeking behaviour, diagnosis and start of treatment.

Accurate measurement of cancer symptom awareness, knowledge and beliefs using validated tools would enable precise measurement of the impact of cancer awareness interventions. Against this background, we conducted a scoping review to identify tools which have been utilised to measure breast and cervical cancer symptom awareness in SSA and evidence of their validity. Scoping reviews differ from systematic reviews in scope, criteria and quality assessment.9,10,11 Scoping reviews cover a broader scope than systematic reviews which have a more clearly defined, narrow scope. This renders scoping reviews useful when attempting to encapsulate and disseminate findings from a diverse body of knowledge. Inclusion and exclusion criteria in a scoping study are developed during study selection unlike in a systematic review where such criteria are predetermined prior to study selection, during protocol development. Scoping reviews present evidence based on key themes but do not delve into assessment of the quality of such evidence, as is the case in systematic reviews. Scoping reviews may be conducted as a preamble – to determine if it is necessary to conduct a full systematic review – or as an autonomous exercise, as we did in this review.


The review was guided by two questions: (1) Which tools have been used to measure symptom awareness in SSA? (2) Have these tools been validated in any SSA populations? Following Colquhoun et al.,12 the review process incorporated the first five stages of Arksey and O’Malley’s six-stage framework for conducting scoping reviews9 with Levac et al.’s enhancements of each stage.10 The five stages are as follows: stage 1: identifying the research question, purpose and objectives of the scoping study; stages 2–4: identifying relevant studies, study selection and charting the data, respectively; and stage 5: collating, summarising and reporting the results.

Identification of relevant studies commenced with a basic search for the terms ‘breast cancer, cervical cancer, awareness, beliefs, measures, Africa’ on Web of Science, Scopus and Ebscohost electronic databases. We then sifted through key studies for potential broader search terms, which generated a list of terms (see Appendix 1). A scoping review of literature was then undertaken in PubMed, Web of Science, Ebscohost, Scopus and Cochrane databases. This process entailed refining the search strategy with the aim of generating as many relevant articles as possible. The final search strings contained the terms ‘breast; cervix*; cancer; neoplasm; symptom*; sign; knowledge; perception*; appraisal; understand*; beliefs; attitudes; behavio$r; tool; scale; measure*]’ in various combinations, with the Boolean phrases AND/OR. The database search was supplemented by articles identified by searching through reference lists of key articles.

We included peer-reviewed journal articles published between January 1997 and February 2017, written in English and describing primary research in breast and/or cervical cancer symptom awareness-related topics in SSA contexts. Given the focus on tool validation which involves evaluating ‘if the measurement tool employed actually measures the intended research concept or construct or if the measurement tools used to quantify the variables provides table or consistent responses’,13 that is, validity and reliability, respectively, the research team limited articles to quantitative research studies. The exclusion criteria were articles in languages other than English, non-peer-reviewed articles and book chapters, grey literature, qualitative studies and studies from low-and-middle-income countries outside SSA. Selection of studies involved consultations among the authors who met as a team to establish consensus.

Ethical considerations

This article followed all ethical standards for a research without direct contact with human or animal subjects.


The PRISMA flow diagram and checklist (see Figure 1)14 demonstrate our search strategy and included studies.

FIGURE 1: PRISMA flow diagram.14

Forty-one studies were included. In these studies, cancer awareness is discussed from various perspectives including symptom knowledge, awareness, perceptions and attitudes about breast cancer, cervical cancer or cancer in general, including risk factors. The studies also discussed healthcare use including delays in seeking treatment, pathways to treatment and screening practices.

Tools and validation processes

Twenty of the 41 studies used symptom awareness tools but gave no detail on tool validation processes3,4,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32 (see Table 1). Twenty-one studies referred to some tool validation processes. Of these, 19 had limited detail of validation (see Table 2),33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52 and two documented thorough validation processes (see Table 3).53,54 Regarding the 19 studies that made some limited reference to validation, two studies noted that they used validated tools but did not test the validity of the tools for themselves.33,34 Three studies tested for internal reliability.35,36,37,38 One of the three studies published two articles each of which assessed test–retest reliability with 20 women.35,36 The second study assessed test–retest reliability with an unspecified group of women with similar characteristics to the study sample,37 while the third study utilised Cronbach’s alpha internal reliability test.38

TABLE 1: Symptom awareness tools identified, no validation details provided.
TABLE 2: Symptom awareness tools identified, some validation details provided.
TABLE 3: Symptom awareness tools identified, thorough validation.

Fourteen studies utilised pilot testing39,40,41,42,43,44,45,46,47,48,49,50,51,52 as follows: two studies documented that they pilot tested their tools but gave no further information39,40; one study specified that they used pilot testing to test reliability of their tool41; one study alluded to their pilot test serving as a reliability (stability) test by identifying their participants as a separate group from that in the actual study42; six studies tested content validity using pilot tests followed by modification of items based on outcomes of the pilot tests43,44,45,46,47,48; four studies utilised piloting for a combination of validity and reliability tests.49,50,51,52 For instance, use of peer review49 and expert review50 to test for content validity or testing construct validity by structuring content in line with relevant subject literature.49 One study provided additional information on the number of items discarded and those retained after piloting, with content categories for the latter.50

Table 3 shows the two articles that gave a detailed account of their validation processes.53,54 Both articles reported a study conducted by a research team from the Academic Model Providing Access to Healthcare (AMPATH) Oncology Institute, based in Eldoret, Kenya. One explored lay perceptions of breast cancer,53 while the other sought to establish the validity and reliability of the UK Breast Cancer Awareness Measure (BCAM)55 in a Kenyan context.54

Naanyu et al.53 modified BCAM items by adding open-format questions relating to symptoms, severity and treatment of breast cancer, to suit their Kenyan audience. The specific questions were not detailed in the article. Furthermore, two open-ended questions were added to the tool as follows: (1) ‘What are some beliefs, opinions and traditions that you have heard from others about breast cancer?’ (2) ‘In your opinion, what are some of the early warning signs of breast cancer, the ways in which one may know first that she or he has this condition?’ (p. 149) The questionnaire was translated into Kiswahili, Kenya’s national language, and this version was subjected to content validation via three focus group discussions consisting of men and women without cancer aged 18 years and above, attending non-cancer outpatient clinics.

Wachira et al.54 focused on the validation of the BCAM in a Kenyan setting, based their work on 1061 women and an additional 48 women who participated in six cognitive focus group discussions. The authors opted to use BCAM in the absence of locally validated tools applicable in the Kenyan context. Of specific interest to this research team were two BCAM domains, breast awareness and perceived barriers to screening, which the Kenyan researchers associated with delays in timely interventions to enhance early breast cancer detection. Cognitive focus group interviews revealed that compound questions in the BCAM knowledge domain (for example, ‘do you think discharge or bleeding [italics added] from your nipple could be a sign of breast cancer?’) were confusing to participants, who recommended that these questions be rephrased for clarity. The study observed variances in cultural interpretation of some items as well as nuances around translation of BCAM items into Kiswahili. For example, participants requested clarification on the BCAM question ‘do you think that redness of your breast skin could be a sign of breast cancer’, noting that unless the top surface of the skin peels off, dark skin would not usually turn red. This resulted in rephrasing of the question to read ‘change in skin colour’ in lieu of redness for contextual relevance.


Our scoping review provides a synthesis of research12 on tools used to measure symptom awareness in SSA and determine if such tools have been validated in SSA settings. In this regard, our review identified gaps in SSA breast and cervical cancer tool validation literature by presenting the extent of research and how this research was conducted11 in the period between 1997 and 2017. Scoping reviews are useful in various research aspects, including: examining the extent, range and nature of research activity; establishing the relevance of conducting a full systematic review; succinctly presenting and circulating research results; and identifying gaps in literature.9 In addressing how the research was conducted, the scoping review was limited to a narrative descriptive account of studies included and not a detailed analysis of the quality of these studies, which would be possible in a systematic review.9

Our findings demonstrate that several tools have been utilised to measure breast and cervical cancer in SSA contexts. SSA countries featured in this review are Botswana,44 Cameroon,29 Democratic Republic of Congo,19 Ghana,3 Kenya,20,23,26,54,55 Nigeria,21,22,24,28,35,36,37,39,40,42,48,50 Sierra Leone,41 South Africa,18,27,32,47,49,51 Tanzania,25,30,31,43 Uganda,15,16,38,46,52 and Zimbabwe.43 Of the 41 SSA studies reviewed, 20 studies utilised tools that were not validated.15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32 The other 21 studies identified tools used and offered information of varying detail regarding validation processes.33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54 with only two of these demonstrating detailed and systematic tool validation processes.53,54 Even so, these two studies are limited in that they show evidence of thorough validation focused on (1) breast cancer but not cervical cancer and (2) only two of the BCAM domains, namely knowledge and/or perceptions of breast cancer and barriers to screening.

Twenty of the 41 studies reviewed were on breast cancer. Of these 20, six utilised tools that were not validated,3,4,17,22,24,28 while 14 used validated tools,33,35,36,37,39,40,41,42,46,47,48,49,50,53,54 including the (1) single study that yielded two articles35,36 and (2) two studies that furnished detailed accounts of their validation process.53,54 Eighteen of the 41 studies reviewed focused on cervical cancer themes. Of these 18, 11 studies utilised tools that were not validated,15,16,18,19,20,21,23,25,26,29,31 while seven utilised validated tools.34,38,43,44,45,51,52 Overall, more breast cancer studies (14) utilised validated tools than cervical cancer studies (7), most of which (11) utilised tools that were not validated. Of the 41 studies, one combined breast and cervical cancer themes,32 while two studies investigated cancer symptom awareness in general but also made mention of breast and cervical cancer symptom awareness among women in SSA.27,30 All three studies used tools that were not validated.


Our results point to the dearth of comprehensively validated and culturally relevant tools to measure breast and cervical cancer symptom awareness in the SSA context and the need for systematic efforts to develop and validate such tools. These findings are consistent with a study on understanding low cervical cancer screening in Uganda, which noted lack of validated tools in African settings.51 Using consistent and reliable measures in cancer studies contributes to the quality of research results,56 which, in turn, will inform oncology practice in so far as ‘standardised, valid measurement is essential for monitoring levels of cancer awareness, examining its risk factors and consequences, and evaluating interventions to promote it’.55

Furthermore, validated tools should be culturally relevant for their intended study populations.53,54,57 The Cancer Awareness Measure (CAM) and the Awareness and Beliefs about Cancer (ABC) tools were developed in the UK to assess cancer awareness in the public; they include generic cancer awareness and cancer-specific measures for breast cancer (BCAM) and cervical cancer (CCAM).58 These tools could be of value in SSA; however, as they were developed in a very different sociocultural setting, they are likely to need adaptation for use in SSA. In our specific study context, validated tools that are culturally relevant in SSA settings will serve as standardised comparative measures to (1) assess breast and cervical cancer awareness, knowledge and beliefs; and (2) enable precise appraisal of breast and cervical cancer awareness interventions. Our findings have informed the development of an African Women Awareness of CANcer [AWACAN] tool to measure breast and cervical cancer awareness.


Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Authors’ contributions

J.M., F.M.W., S.E.S. and A.D.M. initiated the study and developed the study protocol. J.N.G. conducted the literature search, drafted the manuscript, incorporated revisions and prepared the final draft. J.M., F.M.W. and S.E.S. reviewed the articles for eligibility. All the authors reviewed the draft and approved the final manuscript.


This scoping review is part of a project jointly funded by the South African Medical Research Council, MRC UK (via the Newton Fund), GlaxoSmithKline Africa Non-Communicable Disease Open Lab (via a supporting grant Project Number: 023), University of Cape Town and the Cancer Association of South Africa.

This research is linked to the CanTest Collaborative, which is funded by Cancer Research UK [C8640/A23385], of which Fiona M. Walter is Director. The funders had no role in the study design, data collection or decision to publish. Authors retained control of the final content of the publication.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.


The views expressed in the submitted article are those of the authors and not the official position of any of the funders or institutions represented.


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Appendix 1


Crossref Citations

1. Timeliness of diagnosis of breast and cervical cancers and associated factors in low-income and middle-income countries: a scoping review protocol
Chukwudi A Nnaji, Paul Kuodi, Fiona M Walter, Jennifer Moodley
BMJ Open  vol: 11  issue: 5  first page: e044093  year: 2021  
doi: 10.1136/bmjopen-2020-044093